Stage 1
- Sedation
- Propofol + alfenatanil
- 30 degree head up - VAP bundles
- Temp <38 deg
- CPP>60mmHg, ICP < 20
- Vasopressors to maintain CPP if required
- SpO2>97%, PaCO2 4.5-5kPa
- Phenytoin 20mg/kg load maintenance
Stage 2
- Does this patient need a repeat CTH
- Hyperosmolar therapy
- 200mls 20% mannitol
- 200ml PPS
- 20mg Furosemide
- Check plasma osmolarity 320mosm/l
- Hypertonic saline 5% 125mls
- Suction airway
- Paralyse
- Repeat CTH
- Hyperventilation PaCO2 3.5-4.0kPa, SjO2 >55% Licox
- EEG check for any seizures
Stage 3/4
- Does this patient need a repeat CTH
- Decrease CMRO2 guided by EEG
- Propofol 50-200mg
- Monitor
- ICP
- CCP
- SjO2
- Thiopentone loading and infusion to burst suppression
Stage 5
Barbiturate Coma
- Thiopentone—effective at controlling ICP
- Similar effect to other sedatives but additional free radical scavenging effect
- Dose titrated to achieve burst suppression
Adverse effects
- Hypotension
- Reduced cerebral perfusion pressure
- Na accumulation
- Non-reactive pupils
- Prolonged ventilation and recovery
NCCU
- TBI management– placing decompressive craniectomy in context
- ICP < 25 mmHg
- Stage I
- Propofol, fentanyl, atracurium
- 30º head up
- PaCO₂ 4.5-5.0 kPa
- SaO₂ >97%, PaO₂ >11kPa
- Temp < 37 ºC
- Stage II
- External ventricular drain
- CPP > 60 mmHg
- Stage III
- Inotropes / 5% NaCl / Mannitol
- PaCO2 4.0 kPa
- Temp 35 ºC
- Stage IV
- Temp 34 ºC
- Stage V
- Thiopentone
- Decompressive craniectomy
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